Quality improvement in action: my experience as a chief registrar

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Amar Puttanna is 6 months into his post as chief registrar at Sandwell and West Birmingham Hospitals NHS Trust. Here, he showcases the quality improvement work he is leading on to help alleviate the pressures facing his organisation and improve patient care.

The NHS is facing a number of challenges, be it bed pressures, financial constraints or a demoralised workforce. Clinicians and managers alike are trying to find ways to improve patient care and ease the flow of patients through hospital. Through my experience as a chief registrar, a scheme run by the RCP’s Future Hospital Programme, I have come to realise the amount of work and dedication that goes on behind the scenes in the NHS.

The chief registrar scheme was established to empower junior doctors on the ‘shop floor’ to lead local improvement projects, tackling areas in everyday hospital working that are in need of development. Amid the many challenges facing the NHS, during my year in post as a chief registrar I set out to find a way to reduce patient wait times and prevent unnecessary delays in discharges.

A new, collaborative patient pathway

Birmingham Midland Eye Centre is one of the largest eye centres in Europe and receives patients from across the Midlands. The medical team receives a number of referrals for patients with papilloedema (a condition caused by swelling of the optic disc) for further investigation. Previously, patients were referred to the medical unit for review, imaging and further neurology input. Out-of-hours referrals and trainee changeover often resulted in delays in investigations.

With the support of the acute medical unit, neurology, ophthalmology and radiology departments, I aimed to create a simple pathway to reduce the number of delays to patient care. The new process, which is being followed by the medical team, reduces repeat scanning and clarifies management plans.

During my year in post as a chief registrar I set out to find a way to reduce patient wait times and prevent unnecessary delays in discharges.

Quality improvement in action

I was able to optimise this project using the valuable training from the chief registrar education programme offered by the RCP and Faculty of Medical Leadership and Management (FMLM). Before I became a chief registrar, I had limited experience of quality improvement theory and methodology. Following the training I felt confident utilising process maps and identifying which stakeholders to involve.

The open discussions at our training days were also extremely helpful. Fellow chief registrars offered their critiques and different views, ensuring I had looked at all the major aspects to make this project successful.

Improving patient care

This project is having a profound effect on patient experience and clinical care. Efficiency in managing patients admitted with papilloedema has greatly improved due to the clear processes identified in the new pathway. Preliminary data suggests that all patients have been safely discharged the same day with a combined computed tomography (CT) scan (rather than separate CT and CT venogram).

Having these scans at the same time helps clinicians rule out major pathologies at the outset. Previous delays that occurred during out-of-hours have been reduced and patients no longer need to stay in hospital overnight. The reduction in unnecessary scans, repeat scanning or lumbar punctures is also saving money.

Improving the referral process

Inspired by discussions with other chief registrars and the RCP, I decided to create an education tool to improve the referral process within one of the trust’s large district general hospitals. The tool will:

reduce unnecessary referrals

reduce delays in decision making when reviewing referrals

educate referrers in basic investigations for certain conditions

reduce length of stay.

I began to develop the tool by reviewing a selected number of specialties. Through this process we are gaining a good understanding of each specialty’s internal processes, for example which referrals require inpatient review.

Further details were provided specifically for inpatient referrals in order to ensure appropriate investigations had already been organised or performed so that the specialist would have all relevant data promptly to make a clear decision. The data we have collected (from seven specialties so far) will be disseminated to each ward with the aim of aiding referral processes across the hospital. It will also form the basis for grand round presentations, trainee teaching programmes and electronic referral processes at the trust.

Personal development

As a chief registrar I have become a key point of contact for trainees at the trust to discuss improvement initiatives with. The RCP education and training days have also equipped me with the confidence and skills to become a champion for improving junior doctors’ engagement with clinical services and trust management to benefit patient care.

I am thoroughly enjoying being a chief registrar and I am looking forward to using my learning to collaborate with and support my clinical colleagues to further improve patient care.

You can follow Amar’s experience as a chief registrar on Twitter at @AmarPut.